Tick-Borne Illness Information

Fifteen different species of tick have been identified in Maine.  Some of these have durable populations in the state, while others may arrive on wildlife but do not survive long-term.  The three most common tick species in Maine are:

• Blacklegged Tick or Deer Tick (Ixodes scapularis)

• American Dog Tick (Dermacentor variabilis)

• Woodchuck Tick (Ixodes cookei)

While all three of these species of tick are able to carry the bacteria that cause tickborne illness, only the Deer Tick is able to transmit it to humans or other animals.  Adult deer ticks are small (usually less than 1/8 inch in length) and range from reddish orange to brown or black in color, typically with dark brown or black legs.  They increase in size after feeding, sometimes reaching up to 1/2 inch in the fully fed, or engorged, state.

There are three major bacterial tickborne illnesses which are seen on Islesboro in the summer months: Lyme disease, anaplasmosis and babesiosis.  It is possible to be infected with more than one tickborne disease at the same time

Lyme Disease

Lyme disease is the most common tickborne illness on Islesboro.  It is caused by a type of bacteria called Borrelia burgdorferi.  There is no human vaccine currently available for Lyme disease, though a veterinary version is available for dogs.

Typical symptoms include fever, headache, rash, painful or swollen joints and stiff neck.   Temporary one-sided paralysis of the face (Bell's palsy) can sometimes occur and can mimic signs of a stroke.  The rash associated with Lyme disease is typically >3 cm (1.5 inches) in diameter.  It is common to have a small amount of redness around a tick bite because of local allergic reaction to proteins on the surface of the tick's body or in its saliva, and this does not necessarily indicate Lyme disease.  Most cases of Lyme disease can be treated effectively with antibiotics on an outpatient basis. 

Severe cases of Lyme disease can involve the heart, the joints, or the central nervous system, and can require hospitalization for additional testing and IV antibiotics.  Routine screening for cardiac involvement in Lyme disease is not currently recommended, unless cardiac symptoms such as chest pain, shortness of breath, lightheadedness or passing out are also present. 

For individuals who have experienced a tick bite, post-exposure treatment with a single dose of doxycycline within 72 hours of tick removal can help to reduce the risk of developing Lyme disease.  Single-dose doxycycline is generally regarded as safe for patients in all age groups.  Infectious Disease Society of America guidelines recommend post-exposure treatment when all three of the following criteria are met:

• The tick bite was from a species of tick known to carry and transmit Lyme disease

• The bite occurred in a region with a high prevalence of Lyme disease

• The tick was attached for >36 hours

Individuals who have a doxycycline allergy should not take doxycycline following a tick bite.  In individuals who are pregnant or breastfeeding, we may ask for expert advice from your OB/GYN before prescribing doxycycline after a tick bite.  Other antibiotics have not been proven to be effective in preventing Lyme disease following a tick bite.

A note on Post-Treatment Lyme Disease Syndrome

In some patients, persistent symptoms including fatigue, pain, brain fog, anxiety and depression can persist even after full treatment with antibiotics.  This can occur in up to 5-20% of patients following Lyme disease treatment.  Current medical evidence indicates that this does not reflect persistent infection or a failure of antibiotics, but rather occurs because of a combination of persistent immune system activation and changes in brain chemistry resulting from the initial infection.  Additional treatment with antibiotics after the initial course of therapy is not recommended, and increases the risk of side effects including damage to the gut microbiome and development of antibiotic-resistant infections.  Evaluation of persistent symptoms after treatment for Lyme disease may include the following:

• Review of your medications to ensure that your symptoms are not related to a medication side effect or drug interaction

• Testing for other medical causes of your symptoms.  Conditions such as autoimmune diseases, thyroid disease, mononucleosis, sleep apnea, anxiety, and depression can mimic the symptoms of Lyme disease.

• Referral to a rheumatologist, especially for patients with persistent joint pain.  Some of the medications used for treatment of autoimmune diseases such as lupus or rheumatoid arthritis have also shown benefit for patients with persistent symptoms after treatment for Lyme disease.

Anaplasmosis

Anaplasmosis is the second most common tickborne illness seen on Islesboro.  While it is much less common than Lyme disease, Islesboro Health Center typically sees a few cases during each summer season.  Anaplasmosis is caused by a type of bacteria called Anaplasma phagocytophilum.  Dogs and horses can also get anaplasmosis.  Symptoms of anaplasmosis include fever, chills, headache, fatigue, muscle aches, loss of appetite, abdominal pain and nausea.  Rash and joint swelling are not common with anaplasmosis, and suggest a separate or concurrent infection with Lyme disease.  In some cases, anaplasmosis can cause abnormal blood counts and liver function studies.  

In most cases, anaplasmosis can be treated effectively with oral antibiotics in the outpatient setting.  Patients who require hospitalization are often those who need IV fluids because the are unable to keep down food or fluids by mouth.  Untreated anaplasmosis can be dangerous, and can result in respiratory failure, bleeding problems, brain inflammation or organ damage.  People over the age of 65 and those with a weak immune system are at greatest risk for severe disease.  Prompt treatment helps to reduce the risk of serious illness.

There is no vaccine to prevent anaplasmosis, but you can still reduce your risk of tick bites through use of protective clothing, tick repellents, and good safety measures (see "Tick Bite Prevention" below).

Babesiosis

Babesiosis is the least common of the tickborne illnesses on Islesboro, though it appears to be increasing in frequency.  It is caused by a microscopic parasite called Babesia microti.  As with other tickborne illnesses, there is no vaccine to prevent babesiosis.  Common symptoms include fever, chills, muscle or joint pain, nausea, vomiting and fatigue.  Babesiosis can cause anemia by damaging red blood cells.  This can be detected with a blood test.  People over the age of 50, those with a weakened immune system due to conditions like cancer or HIV, those with major health problems (i.e. liver or kidney disease) and those without a spleen are at greatest risk of serious illness.

As with most diseases, the most effective treatment for tickborne illness is preventing infection from occurring in the first place.  A consistent and thorough approach to preventing tick bites reduces your risk of illness, but also reduces the need for antibiotic treatment which can cause side effects and promote antibiotic resistance over time.

Preventive Measures

There are many options to help control tick populations and reduce risks of tick bites.  A summary is provided here.  For a more complete discussion of options for tick control, please go to https://ticksonislesboro.com/ 

• Avoid tick habitats when possible.  Ticks cannot fly or jump, but can transfer onto skin or clothing from tall grasses or thick brush.

• Keep grasses mowed and clear brush away from your home and from areas where pets or children play.

• Keep your property free of food sources for rodents, which are carriers of Lyme disease.  Take food waste to the transfer station regularly, and do not allow it to accumulate it on your property.

• Wear light colored clothing when working outdoors or hiking.  This makes ticks easier to see.

• Wear long pants and long sleeves when hiking or working in tick habitats.

• Tuck pants into socks to prevent ticks from crawling up pant legs.

• Perform a thorough visual inspection for ticks on the skin after hiking or working outdoors.  Pay particular attention to warm, moist areas with a rich blood supply (i.e. underarms, groin, behind the knees, skin folds) and areas that were not covered by protective clothing.

• Bathe or shower within 2 hours of hiking or working outdoors

• Washing clothing in hot water will kill ticks, but washing in cold or warm water does not.  If you do not plan to wash outdoor clothing immediately after use, place clothing in the dryer on high heat for 10 minutes to kill ticks.

• Thoroughly inspect pets for ticks on a regular basis and use a high-quality flea and tick prevention treatment.  Please consult with your veterinarian for product recommendations.  Islesboro Health Center is not able to provide veterinary treatment advice.

Tick Repellents

Consistent use of a high-quality tick repellent when hiking or working outdoors greatly reduces the risk of tick bites and tickborne illness.  When purchasing tick repellent, read the label to check for the active ingredient (which will typically be listed by its chemical name).  The following tick repellents are recommended by the Infectious Disease Society of America for prevention of tick bites:

• N,N-diethyl-meta-toluamide (DEET)

• Picardin

• ethyl-3-(N-n-butyl-N-acetyl) aminopropionate (IR3535)

• Oil of lemon eucalyptus (OLE) - not recommended for children under age 3

• p-methane-3,8-diol (PMD) - not recommended for children under age 3

• 2-undecanoate

• Permethrin - use on clothing only

Permethrin can only be applied to clothing, but is highly effective in both killing and repelling ticks.  All of the other tick repellents on this list can safely be applied to both exposed skin and clothing.  DEET, picardin and permethrin are usually the most readily available.  There is not enough evidence to support a recommendation for products touted as "natural" or "chemical free".  In general, these products are less effective.

Use of combination products containing both DEET and sunscreen is not recommended.  If you need to provide both sun protection and insect protection to the same area of skin, apply sunscreen first and then treat with insect repellent on top of it.

1. Don't panic.  The risk of getting Lyme disease from an attached tick that is removed in the first 72 hours is about 2-3%, and this risk can be decreased further with proper treatment.

2. Remove embedded ticks promptly by pulling the tick straight out using fine-tipped tweezers, or using a specialized tick removal spoon.  Ticks are less likely to transmit disease if they are removed promptly.

• Tick removal spoons are available free of charge in the Islesboro Health Center lobby.  For instructions on how to remove a tick with a tick spoon, please see https://www.tickedoff.com/how-to-remove-ticks/ 

• DO NOT burn an attached tick with a match or cigarette, apply noxious chemicals, or use petroleum products to coax detachment.   Doing so can cause the tick to regurgitate and increase the risk of disease transmission.

3. If possible, save the tick to bring with you to clinic.  We can often determine the tick species by examination under the microscope.

4. Gently wash the area where the tick was attached with mild soap and warm water.  It is not necessary or effective to apply antibiotic creams or ointments.

5. Contact Islesboro Health Center or your primary care provider to discuss post-exposure antibiotic treatment.  Post-exposure antibiotics are effective if given within the first 72 hours of tick removal, so don't panic if you can't get a same-day appointment.

• Currently, the only approved antibiotic regimen for post-exposure preventative treatment is a single dose of doxycycline.  Patients who cannot take doxycycline should talk with their medical provider on a case-by-case basis about the risks and benefits of antibiotic therapy.

• While prolonged courses of doxycycline are not recommended in children under the age of 8, single doses for post-exposure prevention of Lyme disease are safe and effective in all age groups.  Dosing in children is different than in adults.  Ask your provider for guidance.  A liquid formulation of doxycycline is available for children who cannot swallow pills, but is not always in stock locally and may need to be prescribed to a mainland pharmacy.

• Doxycycline for post-exposure Lyme prevention is probably safe if you are pregnant or breastfeeding, but there is not enough evidence to be completely certain.  If this applies to you, we may ask to consult with your OB/GYN for expert guidance.

In some cases, tickborne illnesses can be reliably diagnosed based on clinical signs and symptoms alone.  In cases where the diagnosis is not clear or infection with more than one tickborne illness is suspected, blood testing may be necessary.

Islesboro Health Center can draw blood for tickborne illness testing on our regularly scheduled lab draw days.  Testing requires consultation in advance with a medical provider either by phone or via an office visit.  Because specimens must be processed promptly after collection, we cannot draw tickborne illness labs after hours or on weekends.  If you have an appointment on a day when we do not have personnel available to transport specimens to the mainland, you may be asked to come back on a scheduled lab draw day.

It is possible to be infected with multiple tickborne illnesses from a single tick bite.  Our usual tickborne illness testing covers the three most common tickborne illnesses in the region: Lyme disease, anaplasmosis, and babesiosis.  In some cases, we will also test for Borrelia miyamotoi, although this disease is less common.  There is substantial overlap between symptoms of tickborne illness and other medical problems such as viral infections, thyroid disease and side effects of certain medications.  When medically appropriate, testing for other possible causes of your symptoms may be ordered at the same time as tickborne illness testing.  See below for information about specific tests:

Lyme Disease

Testing for Lyme disease detects the antibodies that your immune system makes to help you fight off the infection.  The test does not detect presence of the actual bacteria in your body.  Antibody testing is the only type of testing that is FDA cleared and recommended under current Infectious Disease Society of America guidelines.  Because it can take time for your body to make enough antibodies for the lab to detect, testing for Lyme disease is not very sensitive for up to 3 weeks after an exposure.  Once antibodies are present, they persist in your blood for a long time, even if you are no longer infected.

Once you have tested positive for Lyme disease, you will continue to test positive for months or even years, even if you are fully treated and the bacteria are no longer present.  There is no role for retesting after completion of antibiotic therapy for Lyme disease.

The Infectious Disease Society of America (IDSA) recommends against routine testing for Lyme disease after a tick bite in patients who do not have symptoms.  IDSA guidelines also recommend against testing removed ticks for the bacteria that cause Lyme disease, because the presence or absence of the bacteria in the tick does not reliably predict whether or not a bitten person will become infected.

There is no test to detect Post-Treatment Lyme Disease Syndrome (PTLDS).

Please allow up to 4 days for results of Lyme disease testing to become available. 

Anaplasmosis

Testing for anaplasmosis detects the genetic material (DNA) of Anaplasma phagocytophilium bacteria in the blood.  Testing for anaplasmosis is covered under US Centers for Disease Control and Prevention guidelines, which recommend this type of testing as the most sensitive method to definitively diagnose anaplasmosis.

Because anaplasmosis affects multiple types of blood cells as well as the liver, we may also order blood counts and liver function tests at the same time if we have a strong suspicion that you have anaplasmosis.  These tests help us to determine disease severity and may help to exclude other possible causes for your symptoms.  The results of blood counts and liver function studies are available much more quickly than tickborne illness testing, and in many cases these tests can be run on site.

The NorDx laboratory that runs anaplasmosis testing for us only runs these tests on Mondays and Thursdays.  Samples can be collected at the same time as testing for other tickborne illnesses, and are stored by the laboratory in a way that preserves their stability until they are ready for testing.  Once the testing is completed, results are usually available within 1 day.

Babesiosis

Testing for babesiosis detects the genetic material (DNA) of the Babesia microtii parasite in the blood.  This testing strategy is recommended by the Infectious Disease Society of America as the most sensitive method to definitively diagnose babesiosis.  Because this test detects components of the Babesia microtii parasite directly, the results of this testing are more straightforward to interpret than the antibody testing used for Lyme Disease.

Because babesiosis can affect red blood cells and the liver, we may also order blood counts, tests for red blood cell breakdown and/or liver function tests at the same time if we have a strong suspicion that you have babesiosis.

The NorDx laboratory that runs babesiosis testing for us only runs these tests on Mondays and Thursdays.  Samples can be collected at the same time as testing for other tickborne illnesses, and are stored by the laboratory in a way that preserves their stability until they are ready for testing.  Once the testing is completed, results are usually available within 1 day.

Tests for Lyme disease and other tickborne illness are analyzed off-site by our mainland partners at NorDx laboratory.  The currently approved tests for tickborne illness exceed the licensing of our in-house laboratory.   Our provider group periodically reviews the approved tickborne illness assays and associated regulatory requirements to determine feasibility of in-house testing.  At this time, the regulatory and personnel requirements to perform this testing in-house would be a substantial cost to taxpayers, without significantly changing our approach to the diagnosis and treatment of tickborne illness.  

Treatment for tickborne illness depends upon the specific tickborne disease, as well as your individual risk factors and the other medications that you take.   Treatment for tickborne illness generally requires medical evaluation at an office visit and may require labs to determine the most appropriate course of therapy.  Possible treatments that may be prescribed include:

Lyme Disease

There are three antibiotics that can be used in the treatment of Lyme disease once clinical symptoms develop.  Usual courses of treatment are 10-14 days.

• Amoxicillin - preferred in children under the age of 8 and in pregnant women

• Doxycycline - used as the first-choice antibiotic in most cases.  Doxycycline cannot be used during pregnancy because it harms the bones and teeth of the fetus.

• Cefuroxime axetil - used as an alternative to doxycycline in patients with a contraindication, allergy or intolerance.  Clinical trials indicate that the cefuroxime axetil and doxycycline are equally effective in treating Lyme disease.  A related medication, ceftriaxone, is the preferred treatment for severe Lyme disease in hospitalized patients.

Azithromycin, clarithromycin, or benzathine penicillin can be used in patients who cannot tolerate any of the above medications, but are typically less effective.

There is no role for antibiotics in the treatment of Post-Treatment Lyme Disease Syndrome.

Anaplasmosis

There are very limited antibiotic options  for treatment of anaplasmosis.  The following are options that your provider may consider.  Usual courses of treatment are 7-14 days.

• Doxycycline - used as the first-choice antibiotic in almost all cases.  As in Lyme disease treatment, doxycycline cannot be used during pregnancy.

• Rifampin - can be used in some cases in patients who have a doxycycline allergy and a mild case of anaplasmosis

Babesiosis

Babesiosis is more difficult to treat than Lyme disease or anaplasmosis, and typically requires a combination of two medications.   Treatment is typically for 7-10 days, though highly immunocompromised patients may require a longer course of therapy. Doxycycline is not effective in the treatment of babesiosis.  Example treatment regimens include:

• Atovaquone and azithromycin - preferred in most cases

• Clindamycin and quinine sulfate - preferred in pregnant women and in patients who did not respond to initial atovaquone/azithromycin therapy.

Patients with severe anemia or other life-threatening complications of babesiosis may require advanced treatments that are only available in the hospital.  These may include blood transfusion for very low blood counts, or a treatment called exchange transfusion that removes parasite-infected blood and replaces it with healthy donor blood.  Exchange transfusion typically requires the resources of a major medical center in Portland, Bangor, Augusta or Boston.

General Principles

Tickborne illnesses are generally treatable with antibiotics.  Choosing appropriate antibiotic therapy requires specialized medical training and may take into account your health conditions, the other medications that you are taking, and any of your medication allergies or intolerances.  It is essential to use antibiotics correctly, as inappropriate use can cause bacteria to develop antibiotic resistance and increase your risk of side effects or toxicity.  The following information is not exhaustive and does not substitute for the advice of a qualified medical provider who is familiar with your health history, but provides general guidance on safe antibiotic use.

• Tell your medical provider about all medications and supplements that you take.  Many antibiotics have drug interactions.

• If you are prescribed antibiotics, take the full course of treatment recommended by your provider even if your symptoms resolve sooner.  Stopping antibiotics early can contribute to antibiotic resistance.

• Never take antibiotics that are not prescribed to you, and never give your antibiotics to others.  Doing so is unsafe, and violates both state and federal law.

• Do not "mix and match" antibiotics.  For most tickborne illnesses (with the exception of babesiosis), there is no role for use of multiple antibiotics.  Using multiple antibiotics or changing antibiotics unnecessarily contributes to antibiotic resistance.

• Do not stockpile unused antibiotics.  They may lose their effectiveness in storage or break down into toxic byproducts over time.  Dispose of unused medications in a manner that prevents release into the environment and keeps them from falling into unauthorized hands.  Prepaid mailing pouches can be obtained free of charge at the Health Center front office to mail unused medications to Stericycle for safe and environmentally responsible destruction.

• Most antibiotics can decrease the effectiveness of hormonal birth control.  If you are sexually active, use a backup method of contraception while taking antibiotics.

Amoxicillin

• Amoxicillin is used in the treatment of Lyme disease.  It is not effective in the treatment of anaplasmosis or babesiosis.  There is not enough evidence to support use of amoxicillin to prevent Lyme disease after a tick bite in people who do not have symptoms.

• Amoxicillin is usually used in patients who cannot be treated with doxycycline.  Most studies indicate that amoxicillin and doxycycline are similarly effective in treating Lyme disease.

• Amoxicillin is generally regarded as safe during pregnancy, and is typically the drug of choice for treating Lyme disease during pregnancy.

• Amoxicillin has drug interactions with other antibiotics and with oral contraceptives.  Tell your provider if you take any of these medications.

Atovaquone

• Atovaquone is used in the treatment of babesiosis.  It is always used in combination with another medication,  never alone.  There is no role for atovaquone in the treatment of Lyme disease or anaplasmosis.

• Patients with severe kidney disease may not be able to take atovaquone.

• Atovaquone has drug interactions with other antibiotics, blood thinners, antivirals, and metoclopramide (Reglan).  Tell your provider if you take any of these medications.

• Cases requiring the use of atovaquone are often more complex.  In some instances, you may be referred to an infectious disease specialist to help with management if you need this medication.

• The safety of atovaquone in pregnancy has not been established.  If you are pregnant and become infected with babesiosis, we may request guidance from your OB/GYN before prescribing treatment.

Azithromycin

• Azithromycin is used in the treatment of babesiosis in combination with atovaquone.  It can also be used in the treatment of Lyme disease in patients who cannot tolerate other antibiotics, but it is less effective.  Azithromycin is not effective against anaplasmosis.

• Treatment of babesiosis requires a longer course of azithromycin than what is typically used for respiratory infections.  Information that you find on the internet about recommended duration of azithromycin may not apply to the treatment of babesiosis.

• Patients with a history of certain types of liver and biliary diseases may not be able to take azithromycin.  Tell your provider if you have ever been diagnosed with a liver or biliary disease.

• Azithromycin can increase the risk of a dangerous abnormal heart rhythm.  Use with methadone, anti-nausea medications, certain medications for mental health, and certain medications for heart rhythm can increase this risk.  Tell your provider about all medications and supplements that you take, and if you have been diagnosed with long-QT syndrome.  In some cases, your provider may decide to obtain an EKG at baseline and periodically during treatment to monitor your risk.

• Azithromycin has drug interactions with blood thinners and antiviral drugs.  Tell your provider if you take any of these medications.

• Use of azithromycin in pregnancy is probably safe, although clinical trial data is limited.  If you are pregnant and need treatment with azithromycin, we may request guidance from your OB/GYN before prescribing treatment.

Cefuroxime axetil

• Cefuroxime axetil is used in the treatment of Lyme disease.  Clinical trials demonstrate that cefuroxime is similar in efficacy to doxycycline in the treatment of Lyme disease.

• Cefuroxime is not effective in the treatment of anaplasmosis or babesiosis.

• There are very few limitations on who can take cefuroxime.  The only true contraindication is a history of an allergy to cefuroxime or related medications.

• Cefuroxime has drug interactions with oral contraceptives, antacids, and probenecid.  Tell your provider if you take any of these medications.

• Cefuroxime is safe for use in children over the age of 3 months.   There is not data on use in children under 3 months of age.  If your child needs treatment with this medication and is under the age of 3 months, we may request expert guidance from a pediatric specialist.

• Use of cefuroxime in pregnancy is generally regarded as safe, although clinical trial data is limited.  If you are pregnant and need treatment with cefuroxime, we may request guidance from your OB/GYN before prescribing treatment.

Clindamycin

• Clindamycin is used in the treatment of babesiosis.  It is always used in combination with another medication,  never alone.  There is no role for clindamycin in the treatment of Lyme disease or anaplasmosis.

• You should not take clindamycin if you have ever had a serious allergic reaction to clindamycin or lincomycin.

• Clindamycin is associated with a particularly high risk of a serious diarrheal infection caused by Clostridium difficile bacteria.  Because of this risk, clindamycin is usually prescribed with great caution.  Tell your provider if you have ever been diagnosed with Clostridium difficile infection before beginning treatment.  Use of multiple antibiotics increases the risk of Clostridium difficile infection, so it is critical only to take those antibiotics that are prescribed by your provider.

• Clindamycin has drug interactions with other antibiotics and blood thinners.  Tell your provider if you take any of these medications.

• Cases requiring the use of clindamycin are often more complex.  In some instances, you may be referred to an infectious disease specialist to help with management if you need this medication.

• Clindamycin is generally regarded as safe for use in children with proper medical supervision.

• Use of clindamycin in pregnancy is generally regarded as safe, although clinical trial data is limited.  If you are pregnant and need treatment with cefuroxime, we may request guidance from your OB/GYN before prescribing treatment.

Doxycycline

• Doxycycline is used in the treatment of Lyme disease and anaplasmosis.  It can also be used to decrease the risk of developing Lyme disease following a tick bite.  It is not effective in the treatment of babesiosis.

• Doxycycline increases the risk of serious sunburn.  Patients taking doxycycline should use sunscreen when outdoors and wear sun-protective clothing, even on overcast days.  Use of tanning beds while taking doxycycline is strongly discouraged.

• Take doxycycline with a full glass of water to decrease the risk of ulcers in your esophagus.

• Foods and medications (i.e. Tums) that contain calcium can bind to doxycycline in the stomach and prevent it from being absorbed.  Avoid taking calcium-rich foods or calcium-containing antacids within 2 hours of your doxycycline dose.

• Doxycycline has drug interactions with blood thinners, other antibiotics, antacids, anti-seizure medications and oral contraceptives.  Tell your provider if you take any of these medications.

• Doxycycline and other drugs in the tetracycline class cross the placenta and can have toxic effects on skeletal development in the fetus.  Use of doxycycline in pregnancy is not recommended.

• Doxycycline was historically not recommended for children under the age of 8 because of potential to cause staining of the teeth.  This has been reexamined and disproven in more recent studies.  Use of doxycycline for 21 days or less is now considered safe in children of all ages with appropriate medical supervision.

• Stockpiling of doxycycline is strongly discouraged.  Expired or improperly stored doxycycline can be toxic.  There have been cases of kidney failure associated with taking expired medications from the tetracycline class (which includes doxycycline).  Expired doxycycline also loses its potency over time, and its use may cause our local species of the bacteria that cause tickborne illness to become antibiotic resistant.

Quinine sulfate

• Quinine is used in the treatment of babesiosis.  It is always used in combination with another medication,  never alone.  There is no role for quinine in the treatment of Lyme disease or anaplasmosis.

• Quinine can increase the risk of a dangerous abnormal heart rhythm.  Use with methadone, anti-nausea medications, certain medications for mental health, and certain medications for heart rhythm can increase this risk.  Tell your provider about all medications and supplements that you take, and if you have been diagnosed with long-QT syndrome.  In some cases, your provider may decide to obtain an EKG at baseline and periodically during treatment to monitor your risk.

• Use of quinine is not recommended in patients who have an irregular heartbeat due to atrial fibrillation or atrial flutter.

• Tell your provider if you have ever been diagnosed with myasthenia gravis, optic neuritis or glucose-6-phosphate dehydrogenase (G6PD) deficiency, as you should not take quinine.

• Quinine has drug interactions with atorvastatin, blood thinners, certain medications used to treat abnormal heart rhythms, as well as with some antibiotics.  Tell your provider if you take any of these medications before starting treatment.

• Quinine can lower blood sugar, sometimes to dangerous levels.  Exercise caution if you take medications for diabetes, or if you take a GLP-1 drug for weight loss.

• If you require surgery while taking quinine, be sure to tell your surgeon and anesthesiologist that you are taking this medication, as it interacts with medications commonly used in anesthesia care.

• Cases requiring use of quinine are often more complex.  In some instances, you may be referred to an infectious disease specialist to help with management if you need this medication.

• Use of quinine in children over the age of 18 months is generally regarded as safe.  There is not definitive data on safety of quinine in children under the age of 18 months.  If your child needs treatment with this medication and is under the age of 18 months, we may request expert guidance from a pediatric specialist.

• The safety of quinine in pregnancy has not been established.  If you are pregnant and become infected with babesiosis, we may request guidance from your OB/GYN before prescribing treatment.

Rifampin

• Rifampin is used in the treatment of anaplasmosis, for patients who cannot tolerate doxycycline.  It is less effective than doxycycline, it is usually reserved for mild cases and for patients whose adverse reactions to doxycycline are severe.  There is no role for rifampin in the treatment of Lyme disease or babesiosis.

• Rifampin will cause bodily fluids, including urine, sweat, sputum and tears, to turn red or orange.  This effect is temporary, harmless, and will go away after you complete treatment.

• Soft contact lenses can become permanently stained during treatment with rifampin. 

• Rifampin should be taken either 1 hour before or 2 hours after a meal, with a full glass of water.

• Patients with liver disease may not be able to take rifampin, or may need special monitoring during treatment.  Tell your provider if you have ever been diagnosed with any liver or biliary diseases.

• Rifampin has serious drug interactions with many antiviral drugs.  If you take atazanavir, darunavir, fosamprenavir, saquinavir (with or without ritonavir) or tipranavir, you should not take rifampin.  Tell your provider if you take any of these medications before starting treatment.

• Rifampin affects the way that your body metabolizes (breaks down) other medications, and it has an extensive list of drug interactions.  Be sure to tell your provider about all medications and supplements that you take before starting treatment.  If you are on a complex medication regimen, we may seek expert guidance from a pharmacist before prescribing.

• Rifampin causes birth defects in animal studies, but we don't have data from human trials.  Rifampin is only used in pregnancy if the potential benefit justifies risk to the fetus.

Medical misinformation about tickborne illness is abundant on the internet, particularly on personal websites, blogs and message boards.  The following digital resources have been reviewed and are consistent with current science, treatment guidelines and clinical best practices:

Ticks on Islesboro 

Columbia University Lyme Disease and Tick-Borne Diseases Research Center 

Mayo Clinic Lyme Disease Information 

Harvard Lyme Wellness Initiative 

University of Maine Cooperative Extension: Tick Lab 

Amoxicillin [package insert].  Research Triangle Park, NC: GlaxoSmithKline; 2006.

Atovaquone [package insert].  Research Triangle Park, NC: GlaxoSmithKline; 2008.

Azithromycin [package insert].  New York, NY: Pfizer; 2021.

Biggs HM, Behravesh CB, Bradley KK, et al.  Diagnosis and Management of Tickborne Rickettsial Diseases: Rocky Mountain Spotted Fever and Other Spotted Fever Group Rickettsioses, Ehrlichiosis, and Anaplasmosis -- United States.  Mortality and Morbidity Weekly Report.  2016;65(2):1-44.

Cefuroxime[package insert].  Research Triangle Park, NC: GlaxoSmithKline; 2015.

Columbia University Irving Medical Center. Lyme and Tick-Borne Diseases Research Center.  https://www.columbia-lyme.org.  Published 2025.  Accessed December 20, 2025.

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